EmailMe Form - LU Employment Academy Prep Class Registration Form

Please select your preferred career track *
Office Administration
Accounting Associate
Cyber Security
Direct Care
Name: *
First Last
Social Security Number *
XXX-XX-XXXX
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone: *
### - ### - ####
Email: *
Birthday: *
MM / DD / YYYY
AGE: *
Best time to call:
Morning
Afternoon
Evening
Preferred Method of Contact: *
Phone call
Email
Gender: *
Female
Male
Choose not to disclose
Race: *
American Indian or Alaskan
Asain
Black or African American
Native Hawaiian/Pacific Islander
White
Hispanic? *
Yes
No
Labor Force: *
Employed
Unemployed
Not in Labor Force
Highest Level of Education: *
No Schooling
Grades 1-5
Grades 6-8
Grades 0-12 (no diploma)
High School Equivalency Certificate
Some Postsecondary, no degree
Postsecondary/Professional Degree
Unknown
Location of Highest Level of Education *
United States Based
Non U.S. Based
Do you have a college degree? *
Yes
No
What is your college degree? *
Associate Degree
Bachelor's Degree
Master's Degree
PHD
None
Barriers to Employment: *
Cultural Barriers
Disabled Individual
Displaced Homemaker
Low Income
English Language Learner
Ex-offender
Exhausting TANF within 2 years
Youth in Foster Care
Homeless
Long-term Unemployed (27 or more weeks)
Low Literacy Levels
Migrant Farmworker
Seasonal Farmworker
Single Parent/Guardian
Referred by:
Community Action Agency
Missouri Job Center
Vocational Rehabilitation
Probation and Parole
Family Services Division
Other
I certify that the information given on this application is true and accurate to the best of my knowledge and belief. I consent to the release of my records maintained by a state or local education agency, including the information on this form and transcripts, grades, certificates, the High School Equivalency, and diplomas earned by me. This information may be used by the Missouri Department of Elementary and Secondary Education and shared with other state agencies for research and reporting purposes. Data shared between agencies includes, but is not limitd to, employment, additional schooling and follow-up servicesprovided to you by agencies indentified in the Workforce innovation and Opportunity Act (2014). Currently, as of this date, I am not enrooled in a secondary school institution or receiving homeschool services.
Signature *
Clear
Date Time *
MM / DD / YYYY